Positive lab evidence for EBV in our patient is as follows :EBV
capsid Antigen –IgM was 152 units/mL(normal <40) and IgG -109
units/mL(normal<20) were positive (CLIA quantitative method) indicating
acute primary Epstein-barr virus infection.. We performed
serologic tests and magnetic resonance to exclude other viral or bacterial
infection, autoimmune disorder and cholangio-pancreatography to exclude
structural problems. Review after two weeks was normal.
One month later she presented with with acute pancreatitis &
serum amylase and lipase were-457units/mL and 398units/mL respectively. There
was no hepato-splenomegaly. She was managed conservatively. She became
asymptomatic in 4 days, serum amylase and lipase returned to normal. . On
follow-up after eight weeks child was normal.
Discussion
Infection-induced acute hepatitis
complicated with acute pancreatitis is associated with hepatitis A virus,
hepatitis B virus or hepatitis E virus. Although rare, Epstein-Barr virus (EBV)
infection should be considered also in the differential diagnosis if the
patient has acute hepatitis combined with pancreatitis more so if they have
features of infectious mononucleosis.
Ka-Hyun Yoon and Jin-Bok Hwang reported acute pancreatitis in a 11-year-old
girl without any clinical symptoms of infectious mononucleosis. It was
confirmed by viral capsid antigen (VCA) IgM, VCA IgG, Epstein-Barr nuclear
antigen and heterophile antibody test. (1).Our case
also has similar presentation.
Pankaj jain ,et al reviewed 124 men with acute viral hepatitis, out of which 7
patients were found to have acute pancreatitis(5.65%). The cause of
pancreatitis was hepatitis A virus in 2 patients, hepatitis E virus in 4
patients, and hepatitis B virus in 1 patient.(2)The pancreatitis was mild and all had
uneventful recovery from both pancreatitis and hepatitis. Lisa Kottanattu,
et al have reported simultaneously seen acute pancreatitis in 14 and acalculous
cholecystitis in 37 patients with primary acute symptomatic Epstein-Barr virus
infection. (3).
Hassib Narchi, et al reported hepatitisin
a 8 year old boy with acute pancreatitis.EBV infection was confirmed by
elevatedS lipase of 1,000 IU/L (normal 30-210.
alanine aminotransferase 182 IU/L aspartate aminotransferase 163 IU/L
(normal 8- 20) and alkaline phosphatase 250 IU/L (normal 250-750 IU/L).) IgM
for EBV viral capsid antigen (EBV VCA) was positive confirming acute primary
EBV infection. (4)
Concurrent acute hepatitis and acute
pancreatitis in a 25 year old male was documented by Jered Cook, et al who came
with 2-day history of abdominal pain, nausea and dark stools. EBV IgM antibody
to the viral capsid antigen and Epstein-Barr nuclear antigen was positive. (5)
Pancreatitis in a
35-year-old woman with a 6-day history of fever and sore throat., vomiting,
upper abdominal pain and tenderness in
epigastrium, and a macular rash across the upper trunk was reported by
Zen Zhu, et al. Serum amylase level of 1300 U/L and lipase level of 1450 U/L .16%"atypical"
lymphocytes on the blood film and, positive viral capsid antigen immunoglobulin
M, negative viral capsid antigen immunoglobulin G (IgG), and EBV nuclear
antigen IgG revealed EBV associated pancreatitis.(6)Go to:.Pancreatitis was even diagnosed after 3 weeks in a dengue
patient by Rajesh, et al (7)
.
Conclusion
. In a case of severe epigastric tenderness
with hepatitis, one must also consider a possibility of EBV induced Acute Pancreatitis.
. Primary acute pancreatitis due to
Epstein-Barr virus infection is usually mild, and recovers fully.
Recurrent pancreatitis is also a possibility.